Introduction

Cleveland_Clinic_Host: Unlike sturdier ball-and-socket joints, the shoulder is like a golf ball on a tee, according to Dr. Peter Evans. It is a joint that is carefully stabilized by a complex arrangement of capsule, ligaments, tendons and muscles that are prone to injury and degeneration. Shoulder instability, arthritis and rotator cuff injuries can lead to shoulder pain.

Today’s speaker, Peter Evans, MD, PhD, is director of the Upper Extremity Center in the Orthopaedic and Rheumatologic Institute at Cleveland Clinic. He came to Cleveland Clinic in 2001 from Johns Hopkins Bayview Medical Center, where he was Chief of the Division of Hand and Upper Extremity, the Division of Sports Medicine, and the Director of Orthopaedic Research.

After receiving his medical degree from University of Calgary in Calgary, Alberta, Canada, Dr. Evans completed a comprehensive surgical internship at the University of Toronto in Toronto, Canada. His orthopaedic surgery residency and shoulder and sports medicine fellowship were both completed at the University of Toronto. In addition, Dr. Evans has a PhD from the University of Toronto, The Institute of Medical Sciences, School of Graduate Studies. Then, Dr. Evans completed a hand microsurgery and arthroscopy fellowship from Wake Forest University School of Medicine in Winston-Salem, N.C. 

Dr. Evans has authored numerous publications and book chapters and has made many presentations at national and international conferences. He is very active in research, including peripheral nerve regeneration and transplantation and clinical outcomes. Dr. Evans' specialty interests include shoulder, elbow, and hand surgery including arthroplasty; sports medicine and arthroscopic shoulder, elbow, and wrist surgery; peripheral nerve regeneration; and transplantation.

Welcome to our Online Health Chat with Dr. Peter Evans. We are thrilled to have you here today for this chat. Let’s begin with the questions.

Diagnosing Shoulder Pain

LuLu: Why are shoulders more prone to injury as we age?

Speaker-_Dr__Peter_Evans: Our tendons age along with the rest of the body. Most tendon tears are due to aging, and 60% of people will experience a tear within their lifetime - albeit asymptomatic.

tms6w: I play volleyball in an adult league. I played in high school, but not in college, and never had any injuries as a younger player. After being back on the court for about 3 months playing once a week, as well as in some all-day tournaments, I noticed pain in my right shoulder. Over the course of 4 months the pain went from moderate to severe. I took 3 months off and returned to the court; the pain was worse than ever before and now affects my daily movement, and even sleeping. I have been seen by a physical therapist twice - once before I took the 3 months off and once after. Because shoulder strengthening exercises haven't worked well, he recommends surgery. Do I have any other alternative treatment options? I am still playing - through the pain - and do not want to give up the sport (or other exercises that are now painful like kickboxing).

Speaker-_Dr__Peter_Evans: You should have an MRI to rule out a tear in your rotator cuff. If you do not have a tear, a cortisone injection may kick start a recovery and should be considered.

DEEKER: I have had a sore shoulder for 5 months. My Dr sent me for 8 therapy sessions with some relief but it didn't last. Would "manipulation under anesthesia" help?

Speaker-_Dr__Peter_Evans: We would need to clarify the cause of the shoulder pain. Is it shoulder tendinitis or do you have a frozen shoulder? Manipulation is only useful in patients with a frozen shoulder, not tendinitis.

BrooksKoenig: I'm a 61-year-old male and have various snap, crackle, and pops when I do relatively gentle Tai Chi warm-up exercises. It doesn't really hurt, but I also seem to have very little strength when my arms are above my head. A few months ago I was trying to roll my kayak (poorly) and strained both shoulders. Are there exercises that would help reduce the sound effects and increase strength or should I start with a more thorough exam of the shoulders?

Speaker-_Dr__Peter_Evans: Sounds effects are unimportant unless they are associated with pain. Pain-free shoulders are often associated with cracks and pops. If you are having discomfort and also weakness, then Physical Therapy would be a good idea to increase your strength in a pain-free manner.

kms22: I am 23 years old and on my second shoulder surgery. I have had a total shoulder reconstruction, I continue to have pain and popping noises, what is the next step if that fails?

Speaker-_Dr__Peter_Evans: It is unclear what you mean by total shoulder reconstruction? Did you have instability of the shoulder and it was stabilized with surgery?

kms22: For clarification, I had a complete instability of the shoulder. The Dr stabilized it with surgery twice; the first time did not work! I am having pain and it is making noise again, like before my second surgery. What would be the next step if this surgery fails too?

Speaker-_Dr__Peter_Evans: The good news is that it has not failed yet. Noise may be present and pain may be there but as long as your shoulder is not dislocating, you are in a better situation than you were previously. Continue rotator cuff strengthening exercises. If the pain persists for more than one year post surgery, you should be re-evaluated.

formerbuckeye: Hi Dr. Evans, I'm an active 64 year old male. After an MRI, I've been diagnosed with a large, 2.5 cm full thickness tear of the distal supraspinatus tendon with the tendon retracted to the level of the acromion on. No significant atrophy. High-grade interstitial tear of the intraspinatus tendon. There is also a 2 cm cystic lesion at the musculotendinous junction...most likely a ganglion cyst. I do have pain that interferes with my activities and my sleep. I am in physical therapy twice a week. Is an operation necessary, or should I continue with physical therapy for now? I do not know about the cyst? Is that something special to be dealt with through surgery or other means? Thank you.

Speaker-_Dr__Peter_Evans: You sound like you have a very significant tear and the good news is that you are not showing atrophy in your muscles yet. If your pain does not improve with 3 months of concentrated physical therapy, you should consider getting the rotator cuff fixed to prevent permanent atrophy and to achieve pain relief.

formerbuckeye: And the cyst, please?

Speaker-_Dr__Peter_Evans: The cyst is degenerative and unimportant. It would be debrided at the time of surgery.

nextexit: What is the long term success rate for a L.A.C.S. procedure for M.D.I. (multidirectional instability) of the shoulder?

Speaker-_Dr__Peter_Evans: Do not have a laser assisted capsular shift procedure. Lasers have been associated with significant cartilage damage in the shoulder. Radiofrequency thermal capsular shift is also associated with poorer outcomes than either arthroscopic suture shift or open suture shift.

PamC: I fell skiing last December and at first was receiving PT for a probable torn rotator cuff. Getting no relief I got an MRI which showed a fracture of my humeral head with everything else normal. I continue to have pain in my arm below my shoulder, sometimes almost excruciating. Will this never heal up?

Speaker-_Dr__Peter_Evans: The MRI is more sensitive than plain films for picking up non-displaced fractures. The treatment you had sounds reasonable. You probably are now suffering from secondary scar from the fracture or secondary rotator cuff injury. The rotator cuff is typically injured first and then the bone breaks. About now would be about the time to reinvestigate this further with another MRI.

Adhesive Capsulitis (Frozen Shoulder)

roxie: I am 58 years old and in April 09, MRI showed I had a full thickness tear in the supraspinatus tendon. I also developed adhesive capsulitis. I've been in Physical Therapy for 7 months with Ortho follow-ups. I've regained about 90% range of motion and my Dr. does not recommend surgery at this point. My question: Does a torn tendon heal and will I be able to resume an active lifestyle of golf, swimming, and tennis without re-injuring the rotator cuff?

Speaker-_Dr__Peter_Evans: Torn tendons do not heal; the only reason to intervene with surgery is if you are having continued pain. Many people can function and do activities with a torn tendon.

shoulders: I had shoulder surgery eight and a half months ago for adhesive capsulitis, subacromial impingement and symptomatic acromioclavicular joint arthrosis. I had Physical Therapy before surgery and for many months after. I still participate in independent water therapy. My range of motion has improved but I am still experiencing a great deal of pain. It was getting better but a few weeks ago the pain started to increase. Is this normal and how long should I expect this pain? If I lift anything with weight it causes an increase in pain. Will I be able to regain my strength?

Speaker-_Dr__Peter_Evans: Recurrence of shoulder pain is not unusual. You should back off of overhead sports, including freestyle and stick with breaststroke. If things do not improve, you should be re-evaluated.

shoulders: What causes adhesive capsulitis? Is it related to Estrogen deficiency or Vitamin D deficiency? Most importantly, want can I do to prevent it from happening again?

Speaker-_Dr__Peter_Evans: Half of the cases of frozen shoulder are idiopathic in origin. The most common association we have is diabetes. There is nothing that we know of to prevent it.

shoulders: After having adhesive capsulitis in both shoulders, four years apart, what is the probability of it occurring again? I am 58 years old.

Speaker-_Dr__Peter_Evans: There is no data to indicate that you will ever get it again.

Shoulder Impingement (Bursitis)

lights: The bicep and rotator questions were my mother's. The next are mine. I have been told by my orthopaedic doctor that I have an impingement in both shoulders. Physical therapy made it worse. Is there a specific course of action I should be following with physical therapy or what's the next step?

Speaker-_Dr__Peter_Evans: Time heals most things. If you have been doing therapy and given it at least 3 months and there is no progress, then a cortisone injection could be considered.

thor: Have been recently diagnosed with bursitis of left shoulder and received one cortisone shot. What is prognosis for success and length of time for recovery and duration?

Speaker-_Dr__Peter_Evans: After your pain decreases you should start Physical Therapy to strengthen your rotator cuff. Your chance of avoiding surgery is 70-80%.

Shoulder Pain & Physical Therapy

nystrom: How long does it take a shoulder tendinitis to 'calm down'? I am having PT and would like to get back to swimming. It has been 4 weeks. Not related to an injury, probably overuse.

Speaker-_Dr__Peter_Evans: There is no time table, if you haven't improved and are not yet making a recovery, you should consider further investigation including an MRI, or else, consider a cortisone injection to kick start your recovery.

gmeabr: I am 63 years old. In May I had A BI-LATERAL knee replacement a NY Hospital for Special Surgery. At the same time I am suffering from bone to bone arthritis in my shoulder. The pain keeps me up at night. I have lost strength and mobility. I am not anxious to jump into another surgery right now. Do you have any suggestions? I am in good health, other than arthritis. I’m afraid to exercise because I am fearful of further injuring myself. I'm receiving Physical Therapy for my shoulder. I'm not sure that it is helping.

Speaker-_Dr__Peter_Evans: Physical Therapy is unlikely to help with arthritis. Intermittent cortisone injections can give you pain relief about 2-3 times a year until you are ready for surgery.

jmeltzer: After rotator cuff surgery (2 tears & bone spur) how many times a day to you recommend PT exercises?

Speaker-_Dr__Peter_Evans: Therapy is individualized. The most concentrated time period is from 1-3 months post-op, and typically involves going to the therapist two times per week and doing your exercises 3 times per day. You will continue your exercises for a full 6 months.

Shoulder Pain & Medications

jmeltzer: I have a question for today's Ortho Dept Shoulder Chat. I recently had rotator cuff surgery in Pittsburgh. Dr does not allow Ibuprofen to treat pain for 6 months. Tylenol® does not work, and I want to replace Vicodin® with a non opiate. Why do "some" doctors feel that Ibuprofen delays muscle healing? Thank you! Jim

Speaker-_Dr__Peter_Evans: If you have had a repair of your rotator cuff as opposed to decompression surgery, your physician is being cautious in order to promote tendon healing. There is some basic science data indicating that tendon healing is delayed with NSAIDs.

Jart: 78 yr old female diagnosed with Osteoarthritis in both shoulders. The MRI shows that the right shoulder has a slight tear in the rotator cuff and I am recently suffering with extreme pain. On Tramadol for the pain, Aleve® and Tylenol® don't seem to work. I am just recuperating from a colectomy (second reconnecting surgery on Dec. 19, '08). Is there an alternative to surgery for the two shoulders? I have had Physical Therapy and I am exercising. X-rays and MRI were done at Lahey Clinic.

Speaker-_Dr__Peter_Evans: If osteoarthritis is your principle diagnosis, the options for treatment are to see if it settles down on its own; use of NSAIDs or Tylenol intermittently; or surgery, which would involve a shoulder replacement.There is no correct answer and the choice remains yours.

Indy: How and why do cortisone injections kick start recovery?

Speaker-_Dr__Peter_Evans: Cortisone is an anti-inflammatory and will calm down the bursitis that is associated with tendonitis. With this pain relief, you are often able to participate in physical therapy exercises. There are also many other things that cortisone does that we do not fully understand. But it works.

Ollie: Is PRP therapy appropriate for a second degree shoulder separation? Thanks.

Speaker-_Dr__Peter_Evans: There is no evidence in the literature to evaluate PRP (prolotherapy or proliferation therapy) for shoulder separation.

Insanity4: I have O.A. in both wrists and I have had the cortisone injections in both wrists as well and it does not help. The Dr told me there is cartilage deterioration in both wrists so there is bone on bone contact. Also I have right shoulder impingement and have been through PT with no help. I went to a D.O. who also deals in prolotherapy and within 2 shots of his solution, which included cortisone, the shoulder felt great. Cortisone in the wrists did nothing, so my question would be are there any suggestions on treatment or therapy for the problem in my wrists? Thanks.

Speaker-_Dr__Peter_Evans: Glad to hear that your shoulders are better. Your wrist arthritis needs to be dealt with by a hand surgeon to identify the origin of your arthritis and treatment options.

Elmer: Can gel injection (e.g. Synvisc) be used on the shoulder for relief of "no cartilage, bone-on-bone" diagnosis at Clinic in 2000.

Speaker-_Dr__Peter_Evans: Synvisc (Hylan GF 20) and hyalgan are hyaluronic acid preparations given for osteoarthritis of the knee. They are only approved for knees by the FDA. There is no approval in shoulder at this time.

Surgical Options: Rotator Cuff, Resurfacing, Replacement

dakbk2: If the bicep tendon has to be cut during a rotator cuff surgery, what is the impact on the future use of the shoulder?

Speaker-_Dr__Peter_Evans: The biceps tendon will scar down and very rarely ever retract. With it cut, there is no functional loss. If it should retract, you will have a more prominent biceps muscle, but it will not cause any functional deficit. There is another head to the biceps that always remains intact and is more important for function.

lights: I am taking Physical Therapy for a torn rotator cuff and torn bicep. Is it possible that the therapy can, at some point, heal the rotator cuff or improve it enough to eliminate surgery? If not, how much time should I give the therapy before considering surgery?

Speaker-_Dr__Peter_Evans: Rotator cuff tears do not heal. However, you can become pain-free and enjoy everyday activities and athletics regardless. Almost 60% of people have a rotator cuff tear before they die, many of which are pain free and they do not know they have them. The only reason to intervene is if you have pain. You should give non-operative treatment about 3 months.

lights: How long does the healing process take after rotator cuff and bicep surgery?

Speaker-_Dr__Peter_Evans: If you had a repair of your rotator cuff, the first 6 weeks are spent in passive range of motion. The second 6 weeks are spent doing active range of motion. After 3 months, strengthening is initiated and you should return to full duties at 6 months. We know that the shoulder continues to improve up to 2 years post-surgery.

flwaea: What is recovery time for shoulder replacement and how many weeks of therapy is average?

Speaker-_Dr__Peter_Evans: Recovery from total shoulder arthroplasty and rotator cuff repair are similar in duration. Most people are 80% recovered by 6 months and fully recovered by 2 years.

Indy: Is surgery the only option for torn rotator cuff injuries?

Speaker-_Dr__Peter_Evans: Most tears go untreated and settle down on their own. A tear does not heal, but the other muscles around the shoulder compensate well for those tendons/muscles that are torn. If pain is not resolved over a period of 3-6 months, than surgery is likely indicated. If your tendon tear is secondary to an injury however, we recommend surgery within 3 months in order to get the best possible outcome. We treat an injury related tear like a broken bone.

boomer1: I have a torn rotator cuff (incurred 1/11/09). I had an MRI that caused two orthopaedic surgeons to say surgery was necessary, but the second doctor said I could try Physical Therapy and come back in three months. I did, and he said surgery would not be necessary. My concern is that one of the "good" muscles/tendons might be damaged in the future, after it is too late to repair the existing tear, and that might be a bigger problem. Would I be correct to assume that a future tear could be repaired without concern about my current tear?

Speaker-_Dr__Peter_Evans: You can go on to have normal function with a rotator cuff tear. You may have some permanent atrophy of the muscle that is attached to the torn tendon. There is some evidence that small tears and partial tears will progress to larger tears. The problem is that we have no way of predicating who will and who will not progress. If your shoulder is asymptomatic, you are doing fine and should not need to be followed further.

Elmer: Is resurfacing an approved technique for the shoulder, bone on bone from osteoarthritis?
 
Speaker-_Dr__Peter_Evans: Yes. We perform resurfacing for younger patients in order to preserve bone stock for possible revision surgery. In patients over the age of 60 years, we typically would not do a resurfacing operation, but instead do a traditional total shoulder replacement. This of course is individualized for each patient.

dolt11: I am 77 years old and arthritis has invaded my body. I have been advised to sign up for one year treatment or shoulder replacement: an arthroscopic removal of bits and pieces: and three cortisone injections.

Speaker-_Dr__Peter_Evans: Once you have established OA in an advanced stage, there is no place for arthroscopic surgery. The only reliable treatment is a shoulder replacement. They work very well and have excellent outcomes with over 90% excellent results. Cleveland Clinic does more shoulder replacements than any other center in the country.

harryn: How do I know when surgery is necessary? I have had an MRI.

Speaker-_Dr__Peter_Evans: When your pain has not improved to your liking despite therapy, analgesics and at least 3 months time.

Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Peter Evans is now over. Thank you again Dr. Evans for taking the time to answer our questions about treatment options for orthopaedic shoulder pain.

Speaker-_Dr__Peter_Evans: Thank you for taking the opportunity to participate in the chat today and ask your questions about shoulder pain and treatment options.

More Information

• To make an appointment with Dr. Peter Evans, or any of the other specialists in the Orthopaedic and Rheumatologic Institute at Cleveland Clinic, please call 866.275.7496.  You can also visit us online at clevelandclinic.org/ortho. 
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This chat occurred on October 26, 2009.

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